Footnotes to the History of Psychiatry

Friday, January 2, 2009

In 1970 Henri Ellenberger noted that the work of Pierre Janet (1859-1947) “can be compared to a vast city buried beneath ashes, like Pompeii. The fate of any buried city is uncertain. It may remain buried forever. It may remain concealed while being plundered by maurauders. But it may also perhaps be unearthed some day and brought back to life” (Ellenberger, p. 409). In recent years, this excavation has begun. Some have only been interested in finding anticipations of their own work in Janet (van der Kolk and van der Hart, 1989; Pitman, 1984). Others, however, have taken into account the historical context in which his work was produced (Carroy and Plas, 2000a; Carroy and Plas, 2000b; Plas, 2000; Crabtree, 2003), suggesting a long overdue beginning of detailed Janet scholarship.

Ian Hacking’s recent discussion of Janet, in his historical and philosophical consideration of multiple personality phenomena, suggests a further opportunity for taking a closer look at Janet. Hacking argued that the clinical form as well as the frequency of “multiples” in late twentieth century were dependent on historically specific concerns. He supported this argument by describing a complex set of factors that converged in the 1880s to open the door for a smaller wave of multiple personality phenomena that occurred at that time (Hacking, 1995, pp. 159-170).

One can demonstrate this convergence by considering the Janet’s earliest work. Done between 1883 and 1889, before he received his medical training, this work formed the basis of Janet’s doctoral thesis in philosophy, published as L’Automatisme psychologique (Janet, 1889). Janet’s detailed descriptions of his early work allow us to appreciate the different guises which multiple personality phenomena have taken in the nineteenth century and twentieth centuries. These descriptions also allow us to unearth a picture of Janet discovering what he took to be a new phenomenon and then coming to critically appreciate the paradox inherent in his discovery.

In both the nineteenth and twentieth centuries “multiples” have been characterized by asymetric memory defects. While the normal, first or waking personality cannot recall what has happened to subsequent personalities, subsequent personalities typically can recall the experience of earlier ones. In the twentieth century subsequent personalities or alters play a variety of roles in relation to the patient, who is apparently a victim of child abuse. Janet, by contrast, worked with patients suffering from hysteria, who experienced a variety of puzzling symptoms. Among his most remarkable early findings was that he could replace an hysterical patient’s waking personality, with all of its symptoms, with another personality that was perfectly normal. He called this phenomenon “complete somnambulism” (Pierre Janet, 1887, 469). This was a “multiple” as remote as imaginable from what has appeared in the United States in recent years.

Influences on Pierre Janet during the 1880s

To fully understand Janet’s discovery of complete somnambulism it is necessary to take into account at least four factors that influenced him during the 1880s (Carroy and Plas, 2000b). Janet graduated from from the prestigious Ecole Normale Supérieure in 1882 and the following year, while teaching philosophy at a Lycée in Le Havre, began looking for a subject for his doctoral thesis. The first influence on Janet was the philosophy he was expected to teach. As a philosophy teacher in a lyceum, Janet’s job was to teach a curriculum overseen by his uncle Paul Janet (1823-1899), a leader of the French school of philosophy known as Spiritualism, not to be confused with “spiritisme”, or communicating with the spirits of the dead. (Ellenberger, 1970, p. 334; Goldstein, 1994; LeBlanc, 2001, pp. 57-69).

Spiritualism was established in the 1820s by Victor Cousin (1792-1867) as a means of combating “empiricism’ or “materialism” which, in his opinion, had had disastrous social and political consequences during the Revolution. While remaining a secular philosophy, with no links to the Catholic church, Spiritualism claimed to provide proof for those principles which were considered necessary to an orderly, stable society: the existence of God, free will, and objective standards of good and evil. Of central importance to Spiritualists was the belief each individual possessed an immaterial and indivisible self. Spiritualism portrayed itself as a science, a psychology, which studied the self through introspection (Goldstein, 1968, p. 260; Brooks, 1998, pp.29-67; Barberis, 2002). Pierre Janet’s decision to study pathological states of consciousness was, consequently, encouraged by his uncle Paul, who saw him as “reconquering this domain” for philosophy (Paul Janet, 1897, p. 556; Carroy and Plas, 2000a).

During the 1880s Spiritualism’s claims, both methodological and empirical, were being vigorously challenged by the philosophical school known as positivism (Barberis, 2000). As a young philosopher Pierre Janet was also influenced by this school. The leading positivist of the day Theodule Ribot taught that philosophical problems could be solved through psychological experiments and that hypnosis was a promising method of experimentation (Pierre Janet, 1915-17; Brooks, 1998, pp. 175-185). He had written two highly influential books introducing French audiences to scientific psychology as practiced in England and Germany. Ribot thought psychology should be pursued according to the “method of the natural sciences.” He adopted the views of Claude Bernard that disease provided an experiment in nature. During the 1880s he published a series of monographs on diseases of Memory, the Will, and Personality, which exemplified this approach (Nicolas and Murray, 1999; Nicolas and Charvillat, 2001). Janet read Ribot while still at the Ecole Normale and followed his monographs as they came out during the 1880s (Brooks, 1998, p. 175).

While Janet took his scientific orientation from Ribot, he was also heavily influenced by the observations and theories of the esteemed neurologist Jean Martin Charcot (1825-1893) and his students at the Salpêtrière in Paris. In 1882, Charcot presented a paper entitled “On the Various Nervous States Determined by Hypnotization in Hysterics” to the French Académie des Sciences. By giving this paper to this audience, Charcot legitimized serious research on a subject that had long suffered from academic scorn and neglect. While Janet was initially interested in studying hallucinations, the ease of finding hysterical patients to serve as hypnotic subjects changed the direction of his research (Ellenberger, 1970, pp. 334-6). At the outset of his research, Janet sought and received guidance directly from Charcot, who was generally regarded as the preeminent expert on hysteria (Pierre Janet, 1892, p. 324). Charcot’s advocacy of the idea that anesthesia was not merely a symptom of hysteria, but the cause of other hysterical symptoms was of particularimportance in Janet’s research. (Pierre Janet, 1925, p. 237).

Popular ideas about hypnosis, sleep and somnambulism were the fourth important influence on Janet. Although initially ignorant of the work done by early nineteenth century magnetizers or mesmerists, Janet, like others who flocked to the study of hypnosis in the 1880s, adopted several of the central tenets of those early workers: Waking and sleep are radically opposed states. When phenomena from one state intruded into the other, the results are pathological. Hypnosis is a form of sleep. Somnambulism is a waking sleep; and post hypnotic phenomena involve the intrusion of sleep states into waking life (James, 1995). Like most educated people in the late nineteenth century, Janet too regarded hypnosis as a form of sleep, and somnambulism as a pathological intrusion of waking phenomena into sleep (James,1995). These unexamined presuppositions colored his interpretation of what he found in his research.

Félida and the question of an unconscious second self

Janet discovered his apparent ability to cure hysteria by creating a healthy second personality while attempting to address an important philosophical problem, namely the possible existence of an unconscious second self (LeBlanc, 2001). This problem emerged in 1876 when Etienne Eugène Azam (1822-1899) published the case of a woman by the name of Félida, who appeared to have what he called “doublement de la vie.” Born in 1843, her father died while she was a baby and as a child she had to earn her living as a seamstress. Although she was a hard worker, she was sullen and taciturn and byage thirteen she was complaining constantly of headaches, neuralgias and other symptoms. By age fourteen she began having almost daily episodes of sharp pain in her temples followed by a period of lethargy lasting for a few minutes. When she awoke she was happy, vivacious and free of symptoms. After a few hours she would return to the lethargic state and then to her ordinary personality, with no memory of the previous few hours. As time passed Félida spent more and more time in her symptom free second state (Azam, 1876).

Because of the dramatic difference between Félida’s two states of consciousness and her inability to remember the second state, the latter was generally accepted as a second self or personality. This spontaneously occurring second personality posed a profound threat to the concept of the unity of the self, which was at the heart of the philosophy of Spiritualism, as advocated by Paul Janet. As Pierre Janet later wrote: “Her history was the great argument of which the positivist psychologists made use at the time of the heroic struggles against the spiritualistic dogmatism of Cousin’s school” (Pierre Janet, 1907, p.78). If Félida had two selves, one of whom could not remember the other, then Spiritualism was built on very shaky ground. A unitary self, responsible for an individual’s actions, was central to Spiritualism’s ideas about morality. In addition, the introspectionist method and its findings made no sense without a unitary self to observe and be observed. As Paul Janet wrote: “if the self can feel double, what does its unity, that spiritualist psychologists consider as the basis of their doctrine, consist of” (Paul Janet, 1876). Félida’s second state also raised serious questions about the idea of somnambulism as a form of sleep. Somnambulism was first observed in 1784 by Amand-Marie-Jacques de Chastenet, Marquis de Puységur (1751-1825). Using techniques he had learned from Franz Anton Mesmer (1734-1815), Puységur found a 23 year old peasant named Victor Race who fell into what seemed like a paradoxical sleep, in which he seemed more awake than in his normal state (Ellenberger, 1970, p. 70). Over the next century, until Félida made her appearance, medical scientists did not seriously attempt to understand this paradox. Although Félida was also brighter and healthier in her second state, Azam, for example, continued to hold the conventional view that this state was a pathological form of sleep (James, 1995, pp.241-2; Carroy, 1991, p.106). When Pierre Janet later independently discovered the same second state, calling it “complete somnambulism,” he was forced to challenge this conventional view.

Lucie and Adrienne

Pierre Janet became personally involved in the controversy over the production of an unconscious second self in 1886. The professor of medicine Hippolyte Bernheim (1840-1919) and the physiologist Charles Richet (1850-1935) had found that some subjects, in experiments involving post-hypnotic suggestion, not only carried out suggestions in an automatic manner, but also acted in ways that seemed to involve independent thought. Subjects could, for example, perform an act, not on waking, but at the end of a specified number of days. This was a feat involving more than suggestion because of the need to keep track of the number of days elapsed. Spiritualist philosophers like Paul Janet worried that “to understand these facts, we must infer an unconscious faculty for measuring time” (Janet, 1886, p.582; LeBlanc, 2001, p. 59).Pierre Janet attempted to reproduce these experiments with a nineteen year old patient he called Lucie, who suffered from daily attacks of convulsions and “délire,” that Janet regarded as due to hysteria. Janet had no difficultyeliminating these hysterical symptoms by producing, “the most complete hypnotic sleep” (Pierre Janet, 1886, p. 577). Once she was “asleep” Janet suggested to her that, on awakening, she would carry out a particular act after hearing him clap his hands six times. When he woke her, she did not remember what had occurred during sleep. While she was distracted by other people talking to her, Janet clapped his hands. On the specified clap she did what he had suggested without being able to explain why she had done it. Such experiments demonstrated that Lucie too could pay attention, count, and use judgment without remembering having done so (Pierre Janet, 1886; Crabtree, 2003).Janet wondered how she could do this. Although there would have been general agreement at the time that Lucie had performed the calculations unconsciously, many researchers, like the English physiologist William Benjamin Carpenter, for example, were inclined to describe such unconscious phenomena in physiological terms, as unconscious cerebration, that is to say in terms of the operations of various centers in the brain (Brown, 1983; Crabtree, 2003). This readily available explanatory option, however, conflicted with Janet’s training within the tradition of Spiritualist philosophy. Influenced by the philosopher Maine de Biran, as well as his uncle, Paul Janet, Pierre he was reluctant to reduce consciousness to brain function, and thereby give up the concept of self. Consequently when Pierre Janet was confronted with evidence of post-hypnotic mental operations, he was inclined to interpret them as due to a rudimentary second consciousness or self. For him, even though Lucie was unaware of why she carried out these post-hypnotic suggestions, they were“conscious” in that they were mental and not physiological phenomena. Nonetheless Lucie’s second consciousness, like Félida’s, posed serious problems for the Spiritualist concept of the self as espoused by Paul Janet (Goldstein, 1994;LeBlanc, 2001, p.64). In 1889 Pierre addressed this problem. Although he abandoned the immediate intuition of the self, that was so important in Spiritualist doctrine, he saved the unity of the self under the heading of “mental synthesis” (Carroy and Plas, 2000a, pp. 237). This compromise was sufficient for Paul Janet, who was able to remark that, “We believe we can conclude that the fact of successive existences strikes no blow at the notion of the self ” (Goldstein, 1994, p. 204).

Not everyone was interested in denying the radical implications of Pierre Janet’s findings. In 1889 the philosopher André Lalande praised Janet for having “proven the fact, long rejected for metaphysical reasons, that there are, in spite of the apparent antinomy of the words, states of unconscious consciousness” (Faure, 1989, p. 937). In 1890 William James proclaimed to the Anglo-Saxon world that Janet had demonstrated that “the total possible consciousness may be split into parts which coexist but mutually ignore each other” (James, 1950, p. 206). Having decided that these post-hypnotic mental operations, represented a rudimentary second self, Janet attempted to communicate with this self while Lucie was awake. Since Lucie’s spoken words indicated no awareness of these mental operations, he devised a creative application of the controversial technique known as “automatic writing,” which “spiritistes” used to receive communications from the dead (Hess, 1991, pp. 59-79; Myers, 1887, pp. 237- 240). While Lucie was talking with someone else, Janet, stood behind her and whispered questions to her. She answered in writing. When asked to look at what she had written, Lucie expressed surprise or denied that she had written what was on the page. Able to communicate with Lucie’s calculating hypnotic state through automatic writing, Janet “baptized” what he regarded as a spontaneously occurring second self with the name Adrienne (Pierre Janet,1886). Among the differences that Janet noticed between Lucie and Adrienne was the fact that Lucie never looked at a page while Adrienne was writing on it, but always looked at the page when she, “herself,” was writing. For Janet this was clearly the result of Lucie’s hysterical inability to feel what her hand was doing. It also suggested that while Lucie did not have tactile and muscular sensations in her hand, Adrienne did. Janet speculated that perhaps Adrienne suffered from none of Lucie’s hysterical deficits. From this he wondered whether all patients with hysterical anesthesias , like Lucie, might not have an unconscious second self, which, like Adrienne, did not suffer from the hysterical symptoms that plagued the waking patient (Janet, 1887). As remarkable as this speculative leap may seem, it was supported by the idea that altered sensitivity of the skin and muscles was the fundamental feature of hysteria. Since the 1850s Victor Jean-Marie Burq (1822-1884) had been using metal plates to treat hysteria in women by removing anesthesias from the afflicted parts of their bodies. Burq believed that, because anesthesia was the essential phenomenon of hysteria, removing the anesthesia, by any means, would eliminate all hysterical symptoms. Because Burq’s metal plates could also interrupt hypnotic trances, it seemed that anesthesia was the basis for both these trances as well as hysteria. In the late 1870s Charcot invited Burq to demonstrate his treatment, known as aesthiogenesis, and affirmed its value (Harrington, 1988). As an admirer of Charcot, it is not surprising that Janet was influenced by Burq’s ideas as he worked with Lucie and other patients in the 1880s (Pierre Janet, 1925a, p. 237). While the fact that Lucie did not remember whatoccurred to Adrienne was crucial to Janet’s view of these states as distinct personalities, he saw this amnesia as secondary to her anesthesia. Indeed Janet saw this dependence of memory on sensation as quite general. In 1889 he went so far as to state this as a law: “When a certain kind of sensation has been abolished, the images and by consequence the memories of phenomena which have been furnished by that kind of sensation are abolished as well ” (Janet, 1889, 136-7).In Janet’s view this anesthesia was not a true anesthesia due to the destruction of a neural capacity, but rather a form of negative hallucination that could be induced in a subject through suggestion or hypnosis (Janet, 1887). Nonetheless he saw all the phenomena surrounding his experiments with Lucie --her hysterical symptoms, her amnesia after being woken from a period of somnambulism and her capacity for automatic writing--as deriving from this anesthesia. His discovery of complete somnambulism depended upon his belief in Burq’s aesthiogenesis. Indeed these experiments with the phenomenon of aesthiogenesis made such a deep impression on Janet, that long after Burq’s ideas had been discredited, he wrote, “Something of our first loves always remains with us. We have much difficulty rejecting, as illusions, studies that interested us in our youth” (Pierre Janet, 1919, vol. 3, p. 75).

To test these ideas Janet conducted further experiments where he found that whatever one personality could do the other could not. By suggesting a deficit to Lucie, he could create a capacity in Adrienne, and by suggesting a capacity to Adrienne he could create a deficit in Lucie. When he tried to push this observation to its logical conclusion, that is, to see if Adrienne could speak, he had difficulty. As he attempted to deepen Lucie’s hypnotic state by making “passes” in front of her face, she became totally unresponsive. Lucie would not speak and Adrienne would not write. After a half an hour, however, the young woman “sat up straight, her eyes at first closed then open.” At his request she began to speak. “But the person who now spoke,” Janet remarks, called herself Adrienne, not L[ucie].” Moreover Lucie “had absolutely disappeared, it was impossible to obtain any manifestation of her” (Janet, 1887, pp.467-8).

He had replaced Lucie with Adrienne. Moreover, as his speculations predicted, Adrienne had none of Lucie’s hysterical symptoms. She also had a complete memory of Lucie’s life and was unresponsive to suggestions. Like Félida’s second self, Adrienne was healthy. Had Janet discovered a spontaneously occurring second self, like Félida’s, or had he created this state of “complete somnambulism”? Regardless, Adrienne could only talk with him for a short time. After about twenty minutes, Lucie, with all her symptoms, returned (Pierre Janet, 1887, p.468).

Janet next began to suggest anesthesias to Adrienne. As he did Lucie recovered her ability to feel. With this her other hysterical symptoms disappeared as did her suggestibility. Soon Janet could no longer communicate with Adrienne. He wondered if he “had killed Adrienne by suppressing the tactile sensibility that perhaps had played an important role in this abnormal synthesis of conscious phenomena” (Pierre Janet, 1887, p. 471). While he accepted his obligation to treat Lucie for her hysteria, Janet regretted having “killed” Adrienne. What intruiged him was the fact that a somnambulistic state which ordinarily existed sub-consciously could be made to exist as an alternate consciousness.

Léonie, Léontine and Lénore

At this time Janet’s only other experience with alternating consciousness was with a 45 year old peasant woman he called Léonie, who had been his first subject (Plas, 2000, pp. 93-8). Léonie readily entered a somnambulistic state, and Janet used automatic writing to communicate with her second self. This second self informed Janet, in writing, that her name was Léontine. Unlike Adrienne, who was a rather rudimentary personage, Léontine had existed for a long time and truly had a mind of her own. On one occasion, for example, after Léonie had returned to her home, Léontine wrote to Janet expressing concern for Léonie’s health (Pierre Janet, 1888, pp. 252-3). When Janet noticed that Léontine, that is Léonie “asleep,” appeared to suffer from hallucinations, he was led to discover a third personality, who called herself Lénore (Pierre Janet, 1888, pp. 267-272).

Strikingly Lénore did not have the hysterical anesthesias that were present in Léonie and Léontine, was not at all suggestible and could remember the whole of Léonie’s life. Like Adrienne, Lénore was healthy. Janet had discovered another instance of complete somnambulism. Lénore, however, disabused naive young Janet of the idea that she represented a spontaneously occurring case of complete somnambulism, as Félida presumably did. Lénore revealed that she had been created twenty years earlier by an animal magnetizer known as Dr. Perrier (Pierre Janet, 1888, p. 272). In contrast to Adrienne’s transient existence, Lénore had persisted and alternated with Léonie over the years. Perhaps Dr. Perrier had deliberately created her to cure Léonie of hysteria.

Jules Janet and Marceline

While Janet’s concerns at this time were primarily philosophical and experimental, the question of whether he could use complete somnambulism therapeutically was hard to avoid. Indeed it wasn’t long after his discoverieswith Lucie and Léonie that he encountered an opportunity to do just that. In 1887 his younger brother Jules, at the time a medical student at La Pitié Hospital in Paris, told him about the case of a twenty year old patient, called Marceline, “who had been reduced to an extreme degree of emaciation and weakness” (Pierre Janet, 1925b, p.803). She would not eat or urinate. She vomited what she was fed by nasogastric tube and had to be catheterized several times a day. She also appeared to have lost all cutaneous sensation and had large gaps in her memory of her life. Because other treatments had failed, Jules Janet was able to get permission to treat her using some of the hypnotic techniques he had learned from his older brother (Pierre Janet, 1910).

Applying the idea that hysteria could be cured by removing anesthesias, Jules attempted cure Marceline’s presumably hysterical illness by using all available means to restore conscious sensation (Pierre Janet, 1925, p.237). To do this Jules first determined what sensations were connected with an altered function and then forced her to recover consciousness of these sensations. If an arm was paralyzed, for example, this involved pinching, pricking, andelectrically shocking as well as mobilizing and massaging it. After each excitation, Jules asked Marceline what she felt and forced her to pay close attention so that she could distinguish one sensation from another, even growling when she made a mistake. To get her to eat he followed the same procedure with her mouth, lips, and pharynx. Marceline complained that this work was hard and painful. At times she grimaced, cried, and twisted her limbs (Pierre Janet, 1910, pp. 521-2).

After ten days, however, Jules succeeded in producing a state quite similar to the complete somnambulism that Pierre had discovered in Léonie and Lucie (Pierre Janet, 1910, p.334). Marceline was transformed. She was able toeat without vomiting and urinate without difficulty. Marceline was more thanmerely symptom free, however. She was a new person. She no longer had large gaps in her memory of her life. She also expressed herself with more vivacity, “… stood straighter,… walked more rapidly. … look[ed] at people when she spoke to them and appeared to have come down from the clouds.” Marceline was, moreover, quite aware of this dramatic change. “It appears to me,” she exclaimed, “that I am really living, that this is a new existence and that I am not afraid to confront it” (Pierre Janet, 1910, p. 485).

In terms of nineteenth century ideas of hypnosis as sleep, however, Marceline’s new existence was a total eclipse of her waking state and self-evidently pathological. Jules and Pierre Janet were concerned about the risks involved in leaving someone “asleep” for a prolonged period. As a result, following each period of complete somnambulism, during which Marceline ate and urinated, Jules woke her. She immediately fell back into her previous state. Her anesthesia, anorexia and annuria returned. In addition she completely forgot what had happened during her period of health. For a time Jules continued putting Marceline into the state of somnambulistic health before every meal and waking her shortly thereafter. When this became too burdensome, Jules and Pierre, with some trepidation, decided to leave her in the somnambulistic state for longer periods. To their surprise she did well. In reporting this at the time Jules was particularly enthusiastic. He wrote that, “ it would be a means of curing hysteria to have her live indefinitely in this state where in effect she would be absolutely complete and would no longer be subject to any disorder” (Pierre Janet, 1925a, p. 239).

After a while her family took her home in that state. A few weeks after returning home, however, “her mother brought Marceline to the hospital in a pathetic state. On the occasion of her menstrual period,... (she) had awoken completely ” (Pierre Janet, 1910, p. 336). She had no memory of her period of health and was very bewildered at finding herself in her own house without understanding how she had left the hospital. Jules was able to reinduce complete somnambulism, and she was then able to remember her previous period of health (Pierre Janet, 1910, p.336). This cycle of recovery and relapse persisted over the next seventeen years until her death from pulmonary tuberculosis. During her periods in the state of somnambulistic health she was able to live independently and achieve some measure of success in her career. She was a virtual “Félida Artificielle,” as Pierre Janet later called her. During each relapse she sought out Pierre Janet, who had taken over from Jules, and requested that he return her to the state of complete somnambulism. The frequency with which Marceline relapsed and the amount of work required to return her to the state of complete somnambulism made this a less than satisfactory treatment. Janet quickly recognized this therapeutic limitation (Pierre Janet, 1910).

Nonetheless Janet’s experience with Marceline transformed his ideas about the nature of somnambulism, multiple personalities and the dichotomy between waking and sleep. How could one consider Marceline’s “waking” state,which was inconsistent with life, her normal one? Janet recognized that this was the position taken by “Azam, as well as all…(other) authors” (Pierre Janet, 1907, p.89). Janet, however, argued that a state in which she could not eat or urinate must not be regarded her normal one. Moreover she had lived for years as a normal child before the onset of her symptoms. Looked at in this light, inducing somnambulism did not involve creating a new state or a new personality, butreturning Marceline to the normal state she had enjoyed as a child (Pierre Janet, 1907, pp.89-92).

If inducing a state of complete somnambulism involved returning Marceline to the healthy state she had enjoyed as a child, then her “awakening,” during which she forgot the state of health, was nothing but a relapse. As Janet began to think of Marceline in terms of recovery and relapse, the notion that her different states were distinct personalities and the idea that somnambulism was a form of sleep began to make less sense to him. How could one call a state in which a patient felt better, remembered more of her life and was more successful a form of sleep, especially if she lived in this state for years? As Janet began to develop his mature theories he came to think of recovery in terms of “excitation” rather than sleep. He began to use the terms “instant clair” and “état alerte” to refer to the phenomenon he had observed in Marceline (Pierre Janet, 1925a, p.50; Pierre Janet, 1910, p. 342). Her illness, he came to think, was due to aprofound reduction in psychological tension. Her instants clairs were, in turn, due to a dramatic increase in tension.

Although Janet’s reflections on Marceline’s cure undercut his convictions about somnambulism and multiple personality phenomena, the drama of sudden recovery and subsequent relapse stayed with him. Janet continued tolook for dramatic cures like Marceline’s, but they were rare. By 1889 he was able to report related findings with his patients Marie and Rose (Pierre Janet, 1889, pp. 108-9). His brother Jules demonstrated the phenomenon on Charcot’s “celebrated subject” known as Witt (Pierre Janet, 1889, p. 179). Over the years, however, among “several thousand” patients, Pierre Janet was able to obtain nothing more than an “imperfect form of complete somnambulism” in fifteencases (Pierre Janet, 1925b, pp. 453-4). Only two patients, Marcelle and Irène, showed the phenomenon clearly enough to warrant extended discussion (Pierre Janet, 1925a, pp. 1-69; Pierre Janet, 1925b, pp. 812-17; Leys, 2000, pp. 112-16).

Janet’s early experiments with hypnosis were based on nineteenth century assumptions about sleep and waking, the nature of the self and hysteria. Based on these assumptions he was able to replace Marceline’s hysterical personality with a healthy second one. His appreciation the paradox of a second personality, which was healthy but asleep, undermined the assumptions on which this work had been based, clearing the way for his ideas about psychological tension. Janet’s work demonstrates how an outbreak of multiple personality phenomena depends on the plausibility prevailing assumptions. Recalling Janet’s encounter with his “Félida Artificielle” should encourage us to 19look closely at the historical and cultural context in which our recent epidemic of “multiples” has occurred.

Thursday, January 1, 2009

During the late twentieth century a number of controversies erupted in the United States over such questions as the genuineness of multiple personality phenomena and the recovery of lost memories of sexual abuse. On one side psychotherapists insisted that the phenomena in question were genuine and that they had been overlooked because of bias and ignorance. On the other side critics argued that overly zealous therapists were unwittingly suggesting the phenomena to their patients and thereby creating unnecessary morbidity. What characterizes these episodes is the polarization that develops between those who have seen the phenomenon and those who have not. It is an embarrassing polarization, seemingly more appropriate to religious disputes of earlier centuries than to twentieth century medical science. While these controversies died down, it is apparently only because the adversaries have withdrawn from combat. As periodic eruptions show, however, both sides still cling to their polarized views of the essential truths in these important clinical issues.

For the historian, what is striking is how frequently such controversies seem to recur. From the royal commission investigating Mesmer's claims, to the debates over somnambulism and spiritualism, through the debate between Charcot and Bernheim over hypnosis, and to the various schools of psychoanalysis the same question has reemerged. Insight into the social-psychology of these controversies has not been lacking, though it seems as if it must be rediscovered with each new eruption of controversy. In 1886 the Belgian philosopher Joseph Delboeuf boldly proposed a social-psychological and historical explanation of the polarizing controversy he was witnessing, that has resonance through the twentieth century to the controversies we have recently been experiencing. "Doubtless there is an action of the hypnotist on the hypnotized--like master, like disciple" he argued in a manner that many would agree with, then and now. Delboeuf, however, went further insisting that, "... the subjects themselves, primarily the first , shape… the person who molds them and, without his knowledge, dictate his method and tactics to him. In this way, turning the proverb upside down, we can say : like subject, like master' [Delboeuf, August 1886, 149]. Delboeuf's formulation not only turns the proverb upside down but provides a way of understanding how polarizing controversies and schools of psychotherapy develop in psychiatry. Delboeuf has, however, received little attention in the anglophone world. He has a small place as a footnote to the history of psychoanalysis. Freud quoted one of Delboeuf's dreams at length to demonstrate how forgotten memories influence the creation of dreams and introduced the interpretation of his own dreams by quoting Delboeuf's modest statement that, “Every psychologist is obliged to admit even his weaknesses if he believes that doing so will throw light on some obscure problem" [Freud, 1900/1961,105]. In France Jacqueline Carroy and Francois Duyckaerts have appreciated Delboeuf's broader significance [Carroy, 1991; Duyckaerts, 1992]. Following up on their work, this paper uses detailed published accounts of Delboeuf’s investigations of patients at the Salpêtrière in Paris, his observations on the subjects of the stage hypnotist Donato and his own experiments in Liege Belgium to describe the observations that led him to his memorable insight into the social-psychology of polarizing controversies in psychiatry.Delboeuf achieved his insight during the polarizing confrontation over hypnosis that occurred in France during the 1880s between the illustrious Parisian neurologist, Jean Martin Charcot and Nancéén professor of medicine, Hippolyte Bernheim. Charcot argued that hypnosis was pathological and could be most readily, if not exclusively found, among hysterics. He had made his reputation as a neurologist by studying dramatic symptom complexes as prototypes of disease entities. Following this procedure in his study of hypnosis, he claimed that he had discovered a distinct three stage process consisting of lethargy, catalepsy and somnambulism, which could be elicited in hysterics. Bernheim , by contrast, saw nothing pathological about hypnosis, and no connection with hysteria. Bernheim came to hypnosis by observing the clinical practice of a country doctor A. A. Liébeault. Liébeault's aim was to heal his peasant patients of a wide variety of ailments, using hypnosis as a vehicle to suggest to them that they return to health. From his observations of Leibault Bernheim persuaded himself that hypnosis did not involve characteristic phenomenon, such as Charcot had found, but merely the imposition of the will of a hypnotist on a simple and passive subject [Ellenberger, 1970; Gauld, 1992].

Born in 1831 and Delboeuf received his doctorate in philosophy and letters in 1855. Before turning his attention to hypnosis, Delboeuf had an active and successful career in philosophy and psychology. He was a skeptic, a rationalist, and an experimental psychologist, with a profound commitment to the concept of freedom. Though skeptical about much of what he heard reported about hypnosis, he was not willing to dismiss the phenomena as mere imposture. As a rationalist he was determined to avoid being seduced by the 'mysteries' of hypnosis and to connect the explanation somnambulistic phenomena to the realm of psychological phenomena already analyzed by scientists [Delboeuf, 1887, 113]. In 1869, for example, he anonymously wrote articles offering naturalistic explanations for the regularly occurring stigmata of the would-be saint Louise Lateau. He even proposed an experiment to test the regularity of their occurrence. His commitment to freedom was such that in 1882, in the midst of the rising tide of positivism, he published an extended argument for the role of freedom, not only in human affairs, but also in the whole material world [Duyckaerts, 1992, 11-13].

When he finally turned his attention to hypnosis, during the last ten years of his life, these philosophic commitments colored his approach and influenced his conclusions. His approach was not that of a neuroscientist, seeking to establish new disease prototypes, or that of a medical doctor attempting to treat patients. As a philosopher with a deep commitment to freedom, he was reluctant to see hypnotic phenomena as either the result of disease, like Charcot, or as the result of mental passivity, as did Bernheim. As a rationalist he was determined to find simple explanations for his observations, As an experimental psychologist he was prepared to test these explanations by constructing experiments designed to prove them false. What is particularly intruiging for the historian of psychiatry is that Delboeuf's skeptical, rationalist, libertarian, and experimental outlook led him not only to a reconsideration of the phenomenon of hypnosis but to a reconsideration of the history of hypnosis itself. His first introduction to animal magnetism, as it was still known, was in college. Reading about a miraculous cure he turned to the library to see what he could read on the subject. By luck he came upon Alexandre Bertrand's Treatise on Somnambulism, written in the 1820s [Delboeuf, 1886a, 441]. Bertrand is well known as a skeptic about the 'fluidist' explanations, who , rather than dismissing the observed phenomena out of hand, sought other explanations. Delboeuf was to adopt a very similar orientation towards the hypnotic phenomena he later observed. Bertrand is less well known for his insightful social-psychological analysis of the controversies swirling around in the 1820s. Bertrand regarded those who saw themselves as possessed by demons and those who felt infused with magnetic fluid as equally unreliable witnesses of what was actually influencing them. He saw the phenomena displayed by these very different subjects as originating in the imagination of a subject. Her magnetizer or exorcist was so impressed by this that he later unconsciously molded other subjects to resemble her [Bertrand, 1823]. Without directly citing Bertrand, Delboeuf was later to offer a very similar analysis of the controversies of the 1880s. Bertrand's influence, however, undoubtedly guided Delboeuf's own experiments and helped him reach his conclusions as rapidly as he did. Delboeuf's direct involvement in hypnosis began in December 1885, when he visited Charcot's clinic in Paris. He had dabbled with hypnosis previously, but lore about its dangers and the stigma attached to its practitioners had always limited how far he went. In Paris he had strong philosophical reasons to challenge one of Charcot's fundamental findings. Delboeuf was concerned by the observation that, on waking, somnambulists could not remember what had occurred during 'sleep'. This troubled him because he had a metaphysical commitment to the idea that nothing, not even a memory, is permanently lost from the universe. Because he regarded personal memory as defining the self, which was the basis of personal identity, the failure to remember what occurred during hypnotic sleep also created the paradox of a person with two identities.At the start of his investigations Delboeuf accepted the commonly held nineteenth century assumptions that hypnosis was a form of sleep and that somnambulism was a form of dreaming. Based on these assumptions was sure that there must be conditions which would allow for remembering what occurred during somnambulism just as there were conditions that allowed for remembering dreams. After Charcot's students demonstrated that subjects did forget what they had done after being awoken from a somnambulistic state, Delboeuf created an experiment in which subjects were woken in the midst of putting out an imaginary fire. As he predicted, they remembered the fire as if it were a dream.As a newcomer to hypnosis Delboeuf viewed Charcot's demonstrations with respect. Nonetheless a number of observations aroused his skepticism. He thought that pictures of ecstatic saints lining the waiting room offered suggestions to patients on how to behave when hypnotized. Charcot's first patient greeted him with such familiarity that Delboeuf thought that she resembled an experimental subject more than a sick person [Delboeuf, 1886, 123]. As he watched Charcot's demonstration of catalepsy, one of the three characteristic stages of hypnosis, Delboeuf recalled that stage hypnotists had demonstrated the same phenomena at least forty years earlier [Delboeuf, Oct 1886, 125]. It was important to Delboeuf's perspective on hypnosis that he never made a distinction between hypnotic phenomena created by stage hypnotists and those observed by doctors. Indeed he seems to have identified more with the stage hypnotists than with the doctors. Even before going to Paris to observe Charcot, Delboeuf had published an anonymous defense of the stage hypnotist Donato, who had been dismissed as a charlatan by “les Parisiens” . Delboeuf saw the medical critique of stage hypnotists as largely turf protection and efforts to legally curtail the activities of men like Donato as an unwarranted and even dangerous restriction of human freedom. His familiarity with the work of these 'charlatans' was an important source of his understanding of the social-psychology of healing movements.After observing Charcot's demonstrations, Delboeuf was inclined to agree with Bernheim that such phenomena were the result of unconsciously suggestive maneuvers [Delboeuf,Oct 1886, 125]. His conclusions were not, however altogether in accord with Bernheim's, revealing the influence of Delboeuf's convictions about human freedom. Delboeuf concluded that what he had observed was due, not just to unconsciously suggestive maneuvers on the part of the hypnotist, but to an excessive willingness to accommodate [un excèss de complaisance] on the part of their subjects. "They could speak,' he insisted, for example, 'but they felt a duty to be quiet' [Delboeuf, Oct 1886, 147]. After leaving Paris, Delboeuf did not go directly to Nancy to observe Bernheim but returned home to Liege to try to reproduce Charcot's results for himself. He initially accepted Charcot's view that hypnosis was easier to induce in hysterical patients, but achieved only mixed results with such patients. Remembering Bernheim's claim that hypnosis were easier to produce in healthy, but simple subjects, Delboeuf began a series of experiments using two sisters who were his servants, without apparent concern about the influence of his role as master on his servants as subjects. Perhaps this worked because Delboeuf conducted his hypnotic sessions like a philosophy professor teaching a new student, at times speaking of giving his subjects 'a little lesson in psychology' [Delboeuf, May, 1886,455]. If his authority facilitated their learning, so much the better. When his experiments with the younger sister, M, were disappointing, Delboeuf decided to try to hypnotize the older sister, J., although he thought she would give him more trouble as a subject, because she was more intelligent than her sister. Contrary to these expectations, she rapidly entered a state of somnambulism and he was able get her to demonstrate a wide range of the phenomena he had observed in Paris. Delboeuf’s interpretation of J…’s rapid progress is remarkable for its contrast with with the the interpretations that both the Salpêtrière and the Nancy schools would have given to such performances. To Charcot and his followers J… would have to have been a hysteric. To Bernheim and his followers she would have been considered merely suggestible. In either case the power would lie in the hands of the hypnotist, while the subject would be either sick or extremely passive. For Delboeuf their roles were reversed. First, he marveled at her “intelligence,” self-consciously emphasizing it was her intelligence that allowed her to learn just what he wanted her to do so quickly and completely that a spectator could not discern just how he communicated his wishes to her. Second, he modestly noted that if his psychological studies had not put him on guard, he could have been fooled into believing that he had influenced her by his thought or will.His realization that his servant was smart enough to fool him, and that he was potentially gullible enough to be fooled into believing that he had power over her, opened the door to his realization that this dynamic could well have been working between largely female subjects and largely male hypnotists throughout the nineteenth century. This must have been, he added, how many magnetizers, honestly, came to believe in the power of their will [Delboeuf, 1886b, 153-4]. While Delboeuf was conducting his experiments with J..., he was invited to observe the work of an amateur magnetizer with a group of teen age boys, all of whom behaved in the same manner when hypnotized. Because of his familiarity with the stage hypnotist Donato, Delboeuf immediately realized that these subjects must have ‘passed through Donato's hands'. As Delboeuf knew, when Donato arrived in a new city, he recruited a cadre of subjects, usually of adolescent boys, who he trained in his method, or as Delboeuf put it, 'poured into his mold'. During public performances Donato called upon these subjects to do things that provoked astonishment and laughter in the audience. It was a group of these boys that the magnetizer had unwittingly discovered, and had made no effort to reshape. Because Delboeuf did not make the standard distinction between hypnosis as used in science and in entertainment, it appeared obvious that the type of subject that Donato created for his commercial purposes was a third type of hypnotic subject along with those “discovered” at the Salpêtrière and at Nancy. Donato’s boys had volunteered to be hypnotic subjects and might be seen as motivated to produce the best possible performance. Indeed, he added, he could put his subject J… into a forth category. Expanding the number of categories of hypnotic subjects by accepting the legitimacy of his own subject J… as well as Donato’s subjects on the same footing as those of both Charcot and Bernheim had important implications for his thinking. His conclusion from this insight is worth quoting:…if the subjects from Salpêtrière and those from Nancy present such remarkable differences, they have probably come from a certain type of training in part intentional, in part unconscious, in part accidental. The hypnotists would have been …inspired by the first results that they obtained and would have endeavored to obtain them subsequently, believing that they were essential and characteristic; the subjects, so influenced and almost guided, would have in their turn be used as models by newcomers who saw them or who heard them talked about; there would be, in this way, instituted a latent teaching supported by different traditions according to the milieux, and so would have given rise to types of schools in conflict today. Delboeuf's conclusion relates not only to the schools in conflict in his day but also to the schools in conflict in our day. More is at stake, however, than an original subject persuading her therapist, hypnotist, magnetizer or exorcist of the genuineness of her performance and he then training future subjects and students in his school. The first subject, her handler as well as future subjects and handlers must be prepared to accept a particular interpretation of the observed phenomena. In one period, demons have explained things for some. In other periods magnetic fluids, messages from the dead and more recently alters. Polarization occurs between those who are prepared and trained to see and believe and those who are not. The process that Delboeuf, and Bertrand before him, described helps explain how such polarizing conflicts develop and perhaps assures that they will continue to recur. Not satisfied with having established this typology of hypnotic subjects, Delboeuf, the experimentalist, also attempted to show that he could transform one type into another. Using imitation, he decided to produce hypnotic subjects in the same mold. First, he had M., who did nothing more than 'sleep', when he hypnotized her, watch J… demonstrate lethargy and catalepsy. As predicted M… was now able to enter these states, something she previously could not do. In a second experiment he had two of Donato’s subjects, who had their own type of hypnotic performance, watch J. and M. In a short time Delboeuf was able to get Donato's subjects to imitate J. and M. point for point. Not only was Delboeuf able to get these subjects to change type, but once they did so they continued to display the new set of hypnotic behaviors. The stability of this learned behavior as well as the failure to observe the learning, Delboeuf argued, created the illusion that scientists like Charcot were discovering naturally occurring phenomena. Having recognized how types of subjects are created and modified, as well as how hypnotists deceive themselves into overestimating their power, Delboeuf was in a position to critique the very assumptions with which he had begun his investigations, namely that hypnosis was a form of sleep. Delboeuf's attitude toward his subjects and his relationships with his subjects were already quite different from either those of Charcot or Bernheim. This led to different perceptions of what was going on during hypnosis. On the question of what, if anything was on subjects’ minds while they were in a state of hypnotic sleep it was easy to assume that nothing was on their minds. Indeed when asked they usually said that they were thinking of nothing. Delboeuf, however, noticed that J… was hardly indifferent to sounds around her. When asked, for example, to wake when the clock struck a particular time, she never failed to do so. For Delboeuf this was clear evidence of mental activity [Delboeuf, 1886b, 155]. With another subject S., who was unusual for the time in that she volunteered to be a subject, Delboeuf, who no longer believed subjects had to forget their somnambulistic state, could simply ask what was on her mind. In a series of experiments where he forbid her from doing things such as writing the number “7”, she complied but became sad. When he asked her why she was so sad she replied, " I cannot do what I want. M. Delboeuf had forbidden me to write ‘7’. It is in spite of myself. I am sad because of the uselessness of the efforts that I make.” Delboeuf found S.’s belief that she was not free and her revolt against the constraints he had imposed on her confirmed his view that subjects are not simply clay in the hands of their hypnotizers. [ Magnétisme Animal 18-19] Delboeuf began his investigations persuaded that hypnosis was a form of sleep and somnambulism was a form of dreaming. These comparisons were essential to his efforts to refute the philosophically provocative assertion that subjects cannot remember their somnambulistic state on waking. Initially, while visiting Charcot in Paris, he attempted to create conditions that allow for remembering. Later he concluded that the whole question of remembering or forgetting was a matter of the type of somnambulist one created. He began to see the idea of hypnosis as a form of sleep as useful metaphor for creating certain phenomena. Making use of this metaphor depended, in turn, on the subject's willingness to accept the hypnotist's suggestion that she was 'asleep.' With this insight Delboeuf went on to claim, somewhat tongue in cheek, that there was no such thing as hypnosis [Delboeuf, 1891-2]. In the last paper that he wrote before his death in 1896, at the age of 65, he more seriously suggested that the term hypnosis no longer be used because it created the misimpression that sleep was involved in the process. Instead he suggested that the term hypnosis be replaced by the term 'psychotherapy', or better yet 'psychodynamics' [Delboeuf, 1892-3]. With this suggestion Delboeuf completed his liberation from the mold of nineteenth century ideas about hypnosis and opened the way to twentieth century ideas about the collaboration of patient and therapist. Perhaps it is not surprising that Freud found so much to learn from the modest Belgian philosopher, who believed in freedom.

Edward M. Brown

As presented to the European Association for the History of Psychiatry, Madrid, Spain, September 2002.

During the nineteenth century general paresis of the insane emerged as a new psychiatric disorder which was extremely common and completely devastating. While retrospective studies have found earlier instances of what may have been the same disorder, the first clearly identified examples of paresis among the insane were described in Paris after the Napoleonic Wars.1 General paresis most often struck people (men far more frequently than women) between twenty and forty years of age. Within a matter of months to a few years after the appearance of the first symptoms, it reduced its victims to a state of dementia and profound weakness. No treatment was known, and patients uniformly died. During the nineteenth century its prevalence came to be widely recognized. By 1877, for example, the superintendent of an asylum for men in New York reported that in his institution this disorder accounted for more than twelve percent of the admissions and more than two percent of the deaths.2 In the twentieth century, with the development of accurate diagnostic methods, general paresis was definitively linked to syphilis and with the development of effective treatment methods for syphilis it has become rare.

While historians have recently effectively applied social, political and economic analyses to psychiatry's past, they have largely ignored the history of general paresis. When they have discussed this disorder, they have treated it as an example of psychiatry's success in defining and explaining disease.3 The history of general paresis of the insane is, however, richer in historical ironies and more revealing of social and intellectual conflicts than such accounts suggest. Ackerknecht, for example, noted that while Antoine-Laurent-Jesse Bayle's "discovery of progressive paralysis as a separate disease picture (in 1822)... was of immense importance," Bayle was nonetheless "caused to leave psychiatry altogether."4Why was there such a contrast between Bayle's fate and the ultimate glorification of his discovery, one might ask. For some like Jacques Postel and Rene Semelaigne this question does not arise because they deny that Bayle was "caused to leave psychiatry." Instead they argue that Bayle was never seriously interested in psychiatry and that he left the field at the first opportunity. This view is, however, implausible. While Bayle may never have had an interest in treating the mentally ill, he was a dedicated researcher. As such it is hard to imagine him abruptly and voluntarily abandoning a field in which he had just made what he regarded as an epochal discovery. Further, as Semelaigne noted, Bayle always followed debates over general paresis and was always ready to defend his priority in the discovery of that disorder.5 Jan Goldstein has proposed a purely sociological explanation for Bayle's departure from psychiatry. Noting that Bayle, was a student of Antoine-Athanase Royer-Collard, a rival of Jean-Etienne-Dominique Esquirol, who was the leader of that circle of psychiatrists which established psychiatry as a profession in France, Goldstein argues that "when Royer-Collard died in 1825, Bayle was without a protector, and Esquirol showed no inclination to take the talented young man, under his wing."6 Goldstein, however, fails to ask why Esquirol would not have wanted to adopt such a talented young man and does not explain why the leading members of Esquirol's circle responded to Bayle's announcement of his discoveries, not only by rejecting his conclusions, but also by ridiculing his logic, his claims to originality and even his writing style. This reaction suggests that Bayle's ideas may have been troubling or even threatening to Esquirol and his followers. After all Bayle was only twenty-seven and had only recently finished his training when Royer-Collard died. Certainly such a youthful protege of a rival could have been dismissed more quietly. Paul Bercherie explains the intensity of the rejection of Bayle's ideas by suggesting that Bayle's contemporaries were misled by his enthusiastic exaggerations and wrongly believed that he was proposing pathoanatomical explanations for syndromes they were familiar with. As a consequence, he argues, they failed to recognize that Bayle's conception of general paresis as a disease was radically innovative.7 While Bayle's enthusiastic and even arrogant style no doubt provoked his critics, as Becherie suggests, the clarity of Bayle's arguments as well as the arguments of his critics leave little doubt that it was precisely because they did understand the radically innovative nature of his ideas that they reacted so violently. In 1960 Leibrand and Wettley noted that the opposition to Bayle's ideas was so strong because these ideas breached the nosology of Pinel and Esquirol.8 What they fail to note is that Bayle went beyond describing a disease which cast doubt on the existing nosology. He also advocated an alternative methodology and criterion for making disease attributions in psychiatry. In doing so Bayle challenged the credibility of the framework which gave legitimacy to the therapeutic and research activities of the dominant school of psychiatry. While later in the nineteenth century Bayle's ideas acquired considerable support, in the 1820s Bayle was an isolated figure who was ostracized because of the threat posed by his ideas.

Pinel's Research Principles The construction of the framework on which psychiatry's therapeutic and research activities were based was begun by Philippe Pinel, the founding father of French psychiatry. Pinel, who was also an important theorist in the post revolutionary reform of general medicine, was particularly concerned to establish both medicine and psychiatry on firm empirical footings and to avoid the speculative excesses of eighteenth century medical theorists. Pinel believed that these excesses could be overcome only by carefully observing symptoms, and classifying diseases according to their external manifestations, in the manner in which naturalists classified living creatures.9 A frequently cited passage from the introduction to the first edition of Pinel's Treatise on Mania, published in 1800 can be taken as a succinct statement of what I will call his research principles:

One who takes mental illness as a particular object of his researches, will make a bad choice by indulging in vague discussions about the seat of the understanding and the nature of diverse lesions; because nothing is more obscure and more impenetrable. But if one restricts oneself within broad limits, only to the study of its distinctive characteristics, as manifested by external signs, and adopts as the principle of treatment only the results of an enlightened experience, one returns to the course which must be followed in general by all parts of natural history, and by proceeding with reserve in doubtful cases, one will no longer have to fear going astray.10

In medicine Pinel's ideas had a short life, being superseded by anatomie pathologique, which sought to correlate symptoms with specific autopsy findings, and gave the latter primacy in defining the nature of disease.11 In psychiatry his views had greater longevity, albeit in modified form. What gave Pinel's ideas this longevity in psychiatry was the conviction that psychiatrists could cure a mental disease, that is eliminate its symptoms, without reference to visible anatomical lesions. The results of psychiatric treatment, not anatomical localization, formed the ultimate basis for psychiatry's diagnostic credibility. Pinel's most influential student J.E.D. Esquirol expressed this position clearly in 1816. After a discussion of the inconclusive results of patho-anatomical studies of the insane, he argued that,"happily" these results were "not indispensable" because "for the cure of madness, it is no more necessary to be familiar with its nature than it is necessary to be familiar with the nature of pain to successfully employ pain relievers and sedatives."12 The treatment on which the profession of psychiatry was built in the early nineteenth century was known as moral treatment. During the 1790s, after taking charge of the Bicetre, an asylum for insane men, Pinel observed the way in which the lay managers of that asylum influenced patients. Based on these observations he developed the idea that the insane could be influenced by moral, that is, essentially psychological, means.13 According to Pinel passions such as joy, anger, fear and sadness affected circulatory, respiratory and gastro-intestinal functions which in turn, by a process of sympathetic influence, affected the functioning of the brain. 14 While not denying that the body was implicated in madness, the psychosomatic logic of moral treatment required that insanity be understood functionally, as a nervous disorder, and not as a result of a visible lesion.15

Georget's Revision of Pinel's Ideas

For Pinel the method of classifying psychiatric diseases by describing symptoms and the method of curing these diseases by removing symptoms through moral treatment were interdependent. Together they formed a framework for research and treatment.16 To the extent that anatomie pathologique was successful in establishing symptom-lesion correlations as the basis of legitimate disease attributions it threatened the psychophysiologic rationale of moral treatment and thereby the credibility of this framework. By the third decade of the nineteenth century some psychiatrists, particularly Etienne Jean Georget, were aware of the limitations of Pinel's ideas and were at pains to revise them. To adequately understand psychiatry's reception of Bayle's discovery of general paresis one must therefore view this reception against the backdrop of Georget's work. This is especially true since Georget, before his death in 1828, was Bayle's most outspoken and articulate critic. In 1820, two years before Bayle's first work on general paresis, Georget published On Madness.17 The aim of this work, it can be argued, was to protect the rationale of moral treatment in terms consistent with anatomie pathologique. While Georget supported Pinel's rejection of eighteenth century speculative systems of pathology, approvingly quoting Pinel's statement of research principles, he took issue with both Pinel and Esquirol because they had described the phenomena of madness, "without demonstrating their source;...(and) described the facts scrupulously without connecting them to a cause."18 Rejecting religious views of the mind, Georget insisted that symptoms represented bodily changes. Moreover, influenced by the phrenologic teachings of Franz Joseph Gall, Georget sought to establish the materialist contention that the brain was the seat of the mind.19 For Georget a credible theory of the cause and cure of madness had to be consistent with anatomie pathologique. Indeed autopsy findings on insane patients formed an important section in De la Folie.20 Georget accepted the view that disease attributions had to be based on specific organ function and not on older humoral theories. As a result he sought "to fix the seat (of madness), to demonstrate the source of the disorders produced, as one does in all other diseases..."21 However,true to his psychophysiological views on madness, Georget also insisted that it was "less on its physical dispositions than on its functions that one must form the divisions of the nervous system; it is thus always that anatomy must follow physiology."22 Georget rejected Pinel's suggestion that the seat of madness might be found in disorders of the intestines.23 Instead he argued that madness was a primary or idiopathic disease of the brain. As a result moral influences could be seen as causing madness by directly influencing the brain and moral treatment as curing madness in the same direct manner. Psychiatrists were, like other doctors, responsible for diseases of a specific organ and, moreover, they had an effective treatment for disorders of that organ.For Georget this was the basis of psychiatry's legitimacy as a medical specialty. If insanity were merely secondary,or sympathetic, to a disorder in another part of the body, he argued, this legitimacy would be challenged. He expressed this opinion as follows:

If (insanity) is idiopathic, the organ from which all the disorders emanate, merits the attention of the doctor: to re-establish its functions,... but if it is sympathetic, it is necessary most particularly to address oneself to its cause, to the distant affection which produces and maintains it; otherwise one can only palliate, ... The treatment of madness must thus especially be founded on the state of the brain...24

Aware that some patients seen in asylums were not curable by moral treatment and that some had lesions of the brain and other parts of the body, Georget protected the psychophysiological rationale of moral treatment by adopting what has been called a dualist position.25 He drew a sharp distinction between acute delirium (le delire aigu) and madness proper. The former he regarded as secondary to intoxications, head trauma and disorders in other organs. It was likely to be both incurable and associated with lesions of the brain or other organs. Madness proper was defined in this scheme as an idiopathic disorder that was not associated with visible lesions but was due to physiologic changes in the brain. It was caused exclusively by the interaction of predisposing factors, such as heredity, and precipitating moral or emotional factors such as grief and fear. It was curable by moral treatment. This distinction between le delire aigu and madness proper was supported by Georget's review of autopsy findings among the insane. On the basis of this review. Georget argued for the value of negative as well as positive autopsy findings. He supported his view that madness was an idiopathic or physiological disorder of the brain by pointing to the fact that autopsies done on patients with madness proper revealed no consistent lesions in the brain.26 Because such lesions could not be found, the success of the direct treatment of madness by moral means, rather than anatomie pathologique, could remain the basis of psychiatry's scientific and professional credibility.

Bayle and the Discovery of General Paresis

Before entering psychiatry, Antoine Bayle had already studied with Rene-Theophile-Hyacinthe Laennec, who was one of the leading advocates of anatomie pathologique, as well as a friend and associate of Antoine's uncle Gaspard-Laurent Bayle.27 Antoine Bayle greatly admired these men and sought to emulate them. He also believed that their ideas were in direct conflict with Pinel's. The younger Bayle saw the teaching of medicine at the beginning of the nineteenth century as divided between two schools, that of Pinel and that of Corvisart, with whom Laennec and his uncle had studied. Of Pinel's teachings in medicine he wrote that, "one could not at all hide the fact that they could lead one astray by making one neglect the organic causes of diseases, by focusing too exclusively on derangements of function."28 According to Bayle, Laennec appreciated this difficulty and felt that the best foundation for medicine was the disciplined search for lesions.29 It is clear that in the conflict which he saw between the medical teachings of Pinel and those of Corvisart, Laennec and the elder Bayle, Antoine Bayle identified with the latter. We do not know just why Bayle entered into psychiatry. Postel and Semelaigne suggest that when Bayle was offered a position in psychiatry by one of his uncle's friends, it was only his poverty which led him to accept. However, we also know that the elder Bayle had written that anatomie pathologique:

had not made enough progress toward sufficiently clarifying the diverse genres of organic diseases: many degenerations which present different structures are still confounded and linked under the same designation. It will be difficult for a long time to remedy these difficulties, because few doctors are placed in a position favorable to making autopsies... to remedy these difficulties... nothing would be more advantageous than an exact monograph on each of the orders or genres which compose the class of (organic diseases).30

While the promise of economic security may have motivated Antoine Bayle to enter psychiatry in 1818, it also seems likely that he saw a position at a psychiatric institution as an opportunity to act on his uncle's suggestion. Certainly psychiatric hospitals at that time presented a rich field for autopsy studies.The younger Bayle began his brief career in psychiatry as an interne at the Royal Asylum for the Insane at Charenton, where he studied under A-A Royer-Collard. Evidence suggests that Bayle and Royer-Collard's relationship was a close one. Both were Royalists; and Bayle's praise for Royer-Collard as a mentor was lavish.31 While at Charenton, Bayle focused his efforts on clinico-pathological research. He performed a great number of autopsies, and when writing about treatment, he cited Royer-Collard's experience rather than his own.32 The substantial prevalence of paralytic symptoms among the insane, as well as the fatal prognostic implications of a diagnosis of paralysis were well known when Bayle entered Charenton. In 1816 Esquirol had noted that a majority of a series of two hundred and thirty patients suffering from dementia were also afflicted with paralysis.33 At about the same time he gave a detailed description of the physical symptoms of this paralysis and noted that death could soon be expected following its diagnosis.34 Paralysis had also been observed at Charenton. Trouseau noted that this diagnosis could be found frequently in the case books of that asylum before Bayle arrived.35 At the time of Bayle's research, the prevailing interpretation of the occurrence of paralytic symptoms among the insane was that these symptoms represented a complication of the insanity. This had been Esquirol's view for some time. In his discussion of madness in the authoritative Dictionnaire des Sciences Medicales, Esquirol, without any particular justification, simply listed la paralysie as a complication along with la phthisie and le scorbut.36 It appears that he regarded it as a complication because the physical symptoms of paralysis occurred after the mental symptoms of insanity and because he could not correlate these symptoms with any particular form of insanity. It is also probable that Esquirol's conception of insanity as a cluster of mental symptoms precluded his seeing a physical symptom like paralysis as other than a complication. It was with this conception of insanity as a cluster of symptoms as well as Esquirol's interpretation of paralysis as a complication that Bayle took issue. Bayle first announced his views about paralysis in his medical thesis in 1822, when he was only twenty four years old. This work presented the results of Bayle's patho-anatomical researches at Charenton. It was divided into three chapters each devoted to describing cases of insanity which were secondary to disorders located outside of the brain. While the chapters on insanity secondary to gastro-enteritis and gout have been forgotten, the fact that they were presented alongside of the chapter on general paresis suggests that Bayle's overall purpose was to establish the clinico-pathological foundation of the idea of symptomatic insanity. Bayle's choice of the autopsy finding "Chronic Arachnitis," rather than either the physical or mental symptoms, for the title of his chapter on general paresis also suggests his angle of vision. This chapter contained the main features of Bayle's ideas on the relationship between the mental symptoms of insanity, paralysis and the results of autopsy .37 It ambitiously rejected Esquirol's view that paralysis was a complication of insanity. Instead Bayle argued that paralysis was only one facet of a complex disorder which included both mental and physical symptoms and which arose secondary to a chronic inflammation of the arachnoid lining of the brain. He described this disorder as occurring in three stages. The first was characterized by a mild paralysis, particularly affecting speech, and a monomania, particularly a monomania involving grandiose ideas. The second stage was characterized by a generalized mania and a worsening of the paralysis and the third by dementia and severe paralysis. In each of six cases, he detailed the clinical course and noted the constant presence at autopsy of an inflammation of the arachnoid membrane. Following the logic of Laennec's anatomie pathologique, he reasoned that all of those symptoms associated with constant pathological findings ought to be regarded as part of a single disorder, and that those pathological finding ought to be regarded as the immediate cause of the symptoms. The first of these cases, Claude-Francois L., was admitted to Charenton in October 1818, shortly after Bayle began his work there. This case provides an example of Bayle's approach to explaining psychiatric diseases. On admission this patient was "in a demented state, with ideas that are predominantly ambitious, and with his partial paralysis ...advanced," By the time of his death, this patient provided Bayle with a fully developed picture of the clinical course of the disease. Finding an inflammation of the arachnoid lining of the brain on autopsy, Bayle concluded that the full course of this patient's illness could be explained by this lesion. After presenting the autopsy findings he asked rhetorically, "Does not this observation prove that the disorder of the intellectual faculties was the symptom of a chronic arachnitis and not an essential delire." 38 Pursuing the conclusion that the lesions he has found are "the anatomic characteristics of chronic mental disturbance," Bayle attempted to explain in detail how these lesions resulted in the particular symptoms observed. Claude-Francois L.'s symptoms began with a loss of consciousness which Bayle argued was due to sudden congestion of the blood vessels of the pia mater and the cerebrum. Bayle explained the difficulty with speech, staggering gait, agitation and monomania which occurred during the second period of the disease as due to the increasing inflammation of the arachnoid lining and an outpouring of serous fluid which pressed on the brain. In the third period the trembling, loss of sphincter control and complete dementia were explained in the same manner as due to chronic inflammation of the arachnoid and increasing pressure on the brain from serous exudate.39

Georget and Bayle

Bayle was aware of Georget's book when he wrote his medical thesis. He noted that Georget's views differed from Pinel's in that Georget regarded madness as "always an idiopathic cerebral disorder." He considered opinions such as Georget's, however, as "too exclusive." It seemed to Bayle that "any physician who is not dominated by any preconceived ideas... will not be able to deny that mental disease is most often idiopathic but sometimes he will find it symptomatic."40 This, he added was the opinion of Royer-Collard. While Bayle's thesis did receive public notice, it did not provoke great controversy.41 In part this was due to Bayle's limiting himself to announcing an exception to the principle of madness as an idiopathic brain disease. The year 1822 was, however, also a year of considerable political turmoil in French medicine. In October of that year the Restoration government dismissed the largely republican faculty of the Paris medical school and replaced them with royalist sympathizers. While this political interference may have hurt the teaching of medicine, it also resulted in the elevation of Laennec, who like Bayle was a royalist, to a position of power.42 This changing political climate must have emboldened Bayle. In 1824 Bayle participated in founding the Revue Medicale, a journal which served as a vehicle for his ideas for a number of years.43 In 1825 he published a theoretical statement of his views in this new journal. This virtual manifesto was provocatively titled "A New Doctrine of Mental Disease." 44 This was strictly a theoretical statement published without data, which Bayle promised to present in a later treatise.45 The most obvious feature of this "new doctrine" was Bayle's ambitious reversal of his earlier position that most mental illness is idiopathic. He now insisted that "sometimes, but very rarely" madness is due to strictly psychological factors affecting the mind.46 In the greatest number of cases, he insisted, madness is due to a physical lesion, most often a chronic inflammation of the meninges, but sometimes a specific or sympathetic irritation of the brain. Another feature of Bayle's "new doctrine" was methodologic. Bayle explicitly rejected Pinel's statement of research principles.47 He also rejected and reversed the approach to symptom-lesion correlations used by those "modern authors" who concluded that one cannot account for the symptoms of madness through organic lesions. According to Bayle they reached this false conclusion because they tallied the frequencies of various symptoms and only then attempted to correlate these frequencies with the frequencies of various lesions found upon autopsy. By beginning with symptom clusters and looking for lesions they failed "to see in the history of a particular patient the organic lesions in opposition to the symptoms which correspond to them..." Consequently they lost the opportunity to explain the symptom through the lesion. Bayle, by contrast, concluded that a disease was present in a particular case when he found a lesion. He then collected a great number of individual histories of madness and linked those with the greatest similarity in a manner which allowed him to arrive at a general doctrine.48 Unlike his thesis, Bayle's "new doctrine" did provoke criticism. Among those provoked was Georget, who, it is likely, spoke for Esquirol and his circle.49 Georget noted that Bayle had dramatically changed his opinions. In 1822, he pointed out, Bayle had agreed with the view that madness is most often idiopathic and only sometimes symptomatic, while in 1825 he reversed himself. "From 1822 to 1825," Georget exclaimed, "what a change!!" Noting that Bayle had been a student at Charenton in 1822 and had not worked there since 1822, Georget went on to suggest that Bayle's earlier views were perhaps only flattery addressed at the men in power at that time.50 He acknowledged that his critique of Bayle was "severe," but justified this severity by what he called Bayle's " exaggerated pretension."51 Had Bayle not announced a "New Doctrine," but rather stuck to his earlier claim to have found only an instance of insanity caused by an inflammation of the meninges, Georget noted that he would not have taken up his pen.52 Georget treated Bayle's "new doctrine" as nothing more than a series of speculative assertions or what he sarcastically called "novelties." Consequently he contented himself with demonstrating that in presenting each of these novelties Bayle was either inconsistent, vague or unoriginal. Of Bayle's claim, for example, that "in one case in five among men and one case in thirty or thirty-five among women... madness is the result of a chronic inflammation of the meninges," Georget rightly noted that the observation of such an inflammation was not new.53 He added that Pinel and Esquirol considered such an inflammation, not as the cause, but as a complication of madness. "It is a question," he asked rhetorically, "of knowing who is right between these doctors and M.Bayle."54 What galled Georget most about Bayle's "new doctrine," however, was Bayle's assertion that "all the doctors who have written before him, all of whom he calls excellent observers," had failed to use the proper method of reaching conclusions about the relationship between symptoms and lesions.55 No doubt regarding himself as one of these excellent observers, Georget did not discuss the substance of Bayle's methodologic position. Instead he concluded this review by dismissively expressing doubt that Bayle could back up his theory with proof.56 The next year Bayle accepted Georget's challenge and published a six hundred page treatise on chronic meningitis, which included a detailed description of ninety cases. He repeated his claim that, "the majority of mental illnesses are the symptom of a primary chronic inflammation of the membranes of the brain."57 As in his thesis he attempted to explain both mental and physical symptoms through the effects of chronic meningitis. He accepted the objection that in "the actual state of science" the question of how an inflammation of the linings of the brain could result in dominant ideas of ambition was "almost insoluble."58 Nonetheless he was willing to conjecture. Rejecting phrenological explanations, he argued that meningitis might be seen as predisposing a patient to certain ideas in the same way as gastritis predisposed patients to hypochondria and pulmonary tuberculosis to unfounded optimism.59 If individuals struck with chronic meningitis were imperious, vain, prideful and ambitious before becoming ill, then "everything unites to give their delusions an analogous character."60 Georget also reviewed this book. He was as sarcastic as before accusing Bayle of writing a book which was "six times too long, the reading of which was as fatiguing as possible."61 He did, however, summarize Bayle's theory and his data lucidly and accurately. Georget was not, as Becherie has suggested, misled into believing that Bayle was merely proposing a pathological anatomy for generally familiar syndromes.62 Rather, he was opposed to what he regarded as the faulty logic of Bayle's accepting autopsy findings as signifying the presence of disease and reasoning from these findings to explain symptoms.Georget based his argument on the first two cases presented in Bayle's book. The first, Claude-Francois L., was a reprint of the same case Bayle had presented in his thesis. This patient demonstrated all three stages of the illness. The second patient choked to death early in the course of the illness. Finding the arachnoid slightly inflamed in the second case Bayle counted it as an example of general paresis, even though the patient presented with monomania but not with paresis. For Bayle these two cases presented autopsy findings at different stages of the same disorder. For Georget treating these two cases as due to the same disease was a failure of logic. According to Georget, Bayle:

didn't have a method of proceeding to arrive at the demonstration of such an opinion; it was necessary to present simple cases, where the phenomena have been observed separately; there are among the insane, ambitious monomanias without paralysis, and paralyses without ambitious monomanias, whatever M. Bayle says to the contrary; it is in comparing the autopsy results from one or another illness that one can perhaps succeed in distinguishing them."63

For Georget the presence of an illness was determined by the careful observation of symptoms. Only when such an illness had been defined did looking for causes make sense. To emphasize this Georget concluded this review by suggesting that bias had prevented Bayle from abiding by Pinel's research principles. "It is necessary," Georget argued, "to assemble a certain number of facts, observed and researched with exactitude, it is necessary to compare them, and to derive all natural inductions; it is necessary to study disorders of movement among the insane, ambitious monomania and dementia, and not chronic meningitis, except to conclude in the end that the affection is the cause of the enumerated symptoms."64

Calmeil

In the same year that Bayle published his treatise Louis Calmeil, like Bayle, a physician at Charenton, but like Georget a student of Esquirol, also published a treatise entitled On Paralysis, Considered among the Insane. Calmeil's several references to Bayle throughout this book, make it clear that he was not merely announcing his own findings, but also responding to Bayle's claims.65 On the opening page of his book Calmeil makes it clear that his opposition to Bayle was stimulated by Bayle's "wanting to establish the extraordinary principle that the majority of the time mental illness has for its immediate cause a physical lesion of the meninges."66 Calmeil reported sixty cases of paresis with autopsy findings on thirty nine. His method of tracing the connections between clinical and post mortem findings differed from Bayle's. He took symptoms, "one by one," observed their development in the manner approved by Pinel and Georget and then predicted what he would find on opening the body.67 In contrast to Bayle's observation of constant pathological findings associated with paralysis, Calmeil found a great variety of lesions at autopsy. Because he found such a variety of lesions, he argued that these lesions could not "sufficiently explain the symptoms observed during life."68 After reviewing the various mental symptoms associated with paralysis, he insisted that one deceives oneself if one concludes that the progression of these symptoms follows the neat three stage model proposed by Bayle.69 Georget reviewed Calmeil's book, predictably praising him for his wisdom and restraint.70 Bayle, on the other hand, responded to Calmeil as sarcastically as Georget had responded to him. Calmeil had concluded that, "it is a chronic inflammation which gives rise to general paralysis, by inducing in the brain a modification which we have not been able to appreciate." Bayle responded by asking rhetorically, "what is this chronic inflammation which has none of the characteristics of inflammations...," that is, does not present with visible lesions.71 The differences between Bayle's and Calmeil's autopsy findings were not a matter of simple empiricism. Laennec had emphasized the importance of inflammatory lesions on the linings of various organs as one of the principle findings of pathological anatomy.72 In defending himself against Calmeil's argument that only an inflammation of the brain, not one of its linings could result in madness, Bayle later suggested that his view of the pathogenic significance of chronic meningitis was supported by its striking analogy with the pathogenic significance accorded to inflammations of other body linings, as for example pleurisy.73 In opening the bodies of the insane Bayle saw what he saw through lenses provided by Laennec. Calmeil, in turn, also saw what he saw through lenses provided him by Pinel.

Monomania

Georget and Calmeil were at such pains to refute Bayle, not only because the logic of his method of linking symptoms and lesions turned theirs on its head or because his claims for the explanatory power of his findings were so broad, but also because the diagnosis of general paresis threatened the disease status of monomania and consequently its ideological value for psychiatry. Originally described by Esquirol, the diagnosis of monomania referred to a symptom complex including exalted mood, increased energy and a preoccupation with a particular idea.74 According to Esquirol, monomania was not merely a disease but it was "of all diseases, the one whose study offers the broadest and most profound subject for meditation:the study of it embraces... that of civilization."75 Moreover, according to Goldstein, Esquirol believed that the fluid society that was the legacy of the Revolution produced its own peculiar monomania, that of overweening ambition. The ideological significance of the idea that changes in the form of monomania reflected changes in the passions of civilization can be seen in Esquirol's suggestion, made in 1822, that a physician's "familiarity with the causes and character of the regnant madnesses" might allow him to furnish the government with the most certain elements of a moral statistics of population.76There is no evidence to suggest that Bayle's aim was to undermine the diagnosis of monomania, even though his conservative religious views probably made him uncomfortable with the implications of this diagnosis.77 Nonetheless by treating monomania, particularly ambitious monomania, as merely a symptom of an inflammation of the meninges, Bayle not only relegated monomania to the status of a symptom, he also undermined the social psychological significance of that disease category. In this light Georget's argument against the constant association of monomania and paralysis can also be seen as an effort to preserve the independent status of monomania as a disease.

Conclusion

In the early nineteenth century Pinel's research principles, which had so effectively separated modern psychiatry from the speculative excesses of earlier centuries, were confronted with the challenge of a new way of thinking about disease. Both Antoine-Laurent-Jesse Bayle and Etienne Georget were aware of the inadequacies of Pinel's position. Both attempted to use autopsy findings to establish psychiatric research on firmer footing. Georget attempted to preserve the Pinel's descriptive approach to symptoms and with it the role of moral treatment in legitimizing psychiatric disease attributions. Bayle, in contrast, rejected Pinel's position outright. Instead he sought to demonstrate, through the discovery of general paresis, the primacy of anatomie pathologique as a methodology and a set of assumptions about disease. Bayle's far reaching claims for the significance of his discovery can be understood in terms of his ambitious advocacy for the approach to disease which his uncle and his mentor stood for. For Georget, however, Bayle's insistence that "the majority of mental illnesses are the symptom of a primary chronic inflammation of the membranes of the brain" threatened the primary role he hoped to establish for brain function as the cause of madness. The united opposition of members of Esquirol's circle to Bayle and his ideas sealed his fate. After Laennec died in 1826, Bayle retired not only from psychiatry but also from clinical medicine, becoming a librarian and bibliographer. Perhaps Bayle, in extending his uncle's legacy to psychiatry, had done all he had intended to do. Georget and Calmeil's reactions to Bayle set the tone for subsequent discussions of Bayle by other authors. As late as 1838 Esquirol in his Maladie Mentale echoed Georget's contention that monomania and paralysis were not constantly associated.78 Even as Bayle's discovery that general paresis of the insane was a distinct disease, involving both mental and physical symptoms and associated with demonstrable pathological findings, came to be accepted, almost ritual references to Bayle's pretensions and exaggerations were regularly expressed. As late as 1855 his claims to priority in the discovery of general paresis were still being challenged.79 It is certainly true that Bayle was provocative and even pretentious in his style. It is also true that Bayle was an outsider whose views would understandably be viewed with suspicion by members of Esquirol's circle. It was, however, the fact that Bayle's ideas threatened the credibility of the framework which which gave legitimacy to the research and therapeutic activities of Esquirol's school, that led to his fate.

72.This is not surprising in that pathological anatomy during the early nineteenth century relied only on macroscopic findings and so many of the people whose bodies were examined had died of inflammatory diseases. Maulitz, Morbid Appearances (n.42), pp.19-25.